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HomeMy WebLinkAbout312 20TH ST - Building Permits A/P/D's for 312 E 20TH ST in Costa Mesa 12:101/25/22011 Level 1 Level 2 Level 3 I Number— 1 Type ., Sub Type I Status_ Date Name '.B06-01438 BLD SUB ' ALT MFR 1 FINALED - 08/29/2006 COLLINS,JAMES B.AND LORIE R. C05-1169 -COMPLAIN OTHER CLOSED 04/12/2005 COLLINS,JAMES B AND LORIE R J C07-0162 COMPLAIN OTHER CLOSED 01/24/2007 COLLINS,JAMES B.AND LORIE R. C07-0368 COMPLAIN TRASH CLOSED 02/27/2007 PORTICO PROPERTIES-NEWPORT HEIGHTS II LLC C07-1994 COMPLAIN TRASH CLOSED 09/28/2007 PORTICO PROPERTIES-NEWPORT HEIGHTS II LLC 1.C08-0161 COMPLAINTRASH CLOSED 01/18/2008 20TH AND SANTA ANA APTS. C08-1137 COMPLAIN i OTHER CLOSED 05/14/2008 COLLINS,JAMES B.AND LORIE R. C11-0096 COMPLAIN BL CODE INVESTIG 01/18/2011 COLLINS, JAMES B.AND LORIE R. E05-00979 ELEC FINALED '109/19/2005 COLLINS,JAMES B.AND LORIE R. i M05-00531 MECH _ FINALED 09/19/2005 COLLINS,JAMES B.AND LORIE R. P05-00721 PLUM FINALED ,09/19/2005 COLLINS, JAMES B.AND LORIE R. P06-00161 J PLUM FINALED 03/10/2006 COLLINS,JAMES B.AND LORIE R. Total Rows: 12 Page 1 p RI FS9 CITY OF COSTA MESA BUILDING DIVISION F •y„rdmimais ,) DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER 4.. IPP4i PERMIT B06-01438 ttbepaninso 4° (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.MULDING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 312 E 20TH ST • - Status: ISSUED Suite: Applied: 08/29/2006 Vicinity: Issued: 08/29/2006 Primary Occ: R Type of Construction: Parcel Number: 42622141 Zoning: Applicant: ROMAN STEPHENS Address: 2025 W BALBOA BLVD a 1111 J SUITE C Phone: 949-689-0539 ISSUED BY: NEWPORT BEACH,CA Zip: 92663 Owner COLLINS, JAMES B. AND LORIE R. Address 2025 W.BALBOABLVD. �./ ElD Phone: 15 sta. NEWPORT BEACH,CA Zip: 92663 wj� Contractor OWNER-BUILDER DAA Address: Phone: Zip: License: 000000 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH INTERIOR WALLS, DOORS,CABINETS,ETC.AND CONVERT ILLEGAL DWELLING UNIT(UNIT 314)TO ITS ORIGINAL USE OF A GARAGE/STORAGE ROOM ONLY. FEE SUMMARY Plan Check: $0.00 Calc Valuation: st,000.00 Permit: $38.75 Claim Valuation: st,o0o.00 SMIP Res: $0.50 SMIP Corn: $0.00 .- Other: $0.00 Inspection: $0.00 Total: $39.25 • PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 ' Right 0-0 ACCESSORY Front' 0-,0 , : Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1,12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 • 2446-46(6/00) • DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: • ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier end policy number are: Carrier: - Policy Number: /��(Thi section need not be completed it the permit is valued at one hundred dollars($100)or less.) l :jai: cedi fy that In the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' CCCC���� compensation laws of California,and agree that If I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with thesep���p/fpsions. -Applicant'Signature:,r rip Mg N J. >regift i./s oaip: :4—.�?9—[5 c -WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST.MID ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,end my license is in lull force end effect.Uc.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors Ucense Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): I as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors Ucense Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I.as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.704-4.Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors Ucense Laws.). I ex under sec.q Business and Professions Code for this reason: �$ignai►waa� ,.,,� roc O (e `bw`ne'r ID verified by driver's li se. ❑Yes 0 No !,Driver's Ucense No. /P Verification of Ownership by(type of document,i.e.-property tax bill or deed). l: DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Wilt the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Flre Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature end pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a_ppIJermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agoncy? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No B (If"yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,end authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of egaI Own ) Date Cd ra,<C..- _ Lem C. — �f'c9e7 O-� Ar_ uthonz Applicant" • ^...,,. Date, • CODE 4 INSPECTION TYPE MTh ',MAL* CODE! INSPECTION TYPE. PATE II$1M618 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 20B Final Plumbing • 200 Final Re-Root 210 Final Electrical • 201 Final Block/Retaining Wall 212 Final Fire Prevention • • 202 Final Factory Fire Place . 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition - 250 Final Building/Occupancy DECLARATION OF AUTHORITY Bldg. Permit# FOR AGENTS OF PROPERTY OWNER This Permit# TO APPLY FOR PERMITS Street Address: 3f2 cf • 0D erlf ST Mn&g, ` AP Number: 03JI r 1. I (we), f72-f( f br-f y w o/ 1/4 S , declare that I am the Owner of Title of the above referenced real property, and that I (we)hereby authorize: �� 90q • �(7' •0119 Name: O/YILtv�— C {ref S Telephone Number: Street Address: 070-5 GO . Fa? Aram / >1 C27-1.06'3 City: ��01 � State: ��•G Zip: to obtain permits in my behalf,as owner/builder,for G(,(J i 1' e/ at the above referenced property. 2. Should any person become an employee engaged in the improvement of the property, I (we)shall immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa, as required by State of California laws. 3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjury that the foregoing is true and correct. Nee / � Executed this .3 1 day of 41 u 5 T 20 Dia , atf. Ao i- "eted1•, California. • r ' Print Name: ,rw a / S Signature:S SIL, Date: • — '1 .0 - Note: This authorization does not grant authorization to perform the work as owner, it solely provides for limited power of attorney to secure this permit in any behalf. 077946(rev 11/00) n CITY OF 4OSTA MESA . \ BUILDING DIVISION > , DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER t I7� . PERMIT • J � E05-00979 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa,g@.us ECTRICAL PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 312 E 20TH ST �L Status: ISSUED Suite No Applied: 09/192005 Vicinity: ILLEGAL UNIT 314 Issued: 09/19/2005 Parcel Nunmber: 42622141 Applicant: STEPHENS, ROMAN ������,,r�'11 Address: 5091 HAMER LANE ISSUED BY: 1"i/% Phone: 949-689-0539 PLACENITA,CA Zip 92870 Owner: COLLINS, JAMES B. AND LORIE R. Address 2025 W.BALBOABLVD. Phone: NEWPORT BEACH,CA Zip: 92663 swgIBB Contractor OWNER-BUILDER DA'Z'E'-sj� Address: Phone: Zip: License:000000 SCOPE OF PERMIT CAP ELECTRICAL FOR REMOVAL OF ILLEGAL UNIT,314 E 20TH STREET. lick, C o.5 . i I 12 c FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System/Lighting $0.00 0 Temp service test $0.00 Busway/100 ft $0.00 0 Res.a/c package $0.00 Standing Section $0.00 0 New Res(1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res(3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool/Spa $0.00 0 up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 up to 50 kva/kw $0.00 0 Recept Outlets $0.00 0 up to 100 kva/kw $0.00 0 Switches $0.00 0 over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System/Ckt $0.00 0 Service to 200a $0.00 0 Misc.Conduit $0.00 0 • Service to 1000a $0.00 0 Misc.Conductor $0.00 0 Service over 1000a $0.00 0 Circus(gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus(mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 • Motors to 50hp $0.00 0 Fireworks Stand • $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $9.80 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $33.30 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $66.60 Intermed Pole $0.00 0 COMMENTS/SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration.of this permit. FOR INSPECTIONS CALL: (714)754-5626 2446-48(WOO) DECLARATIONS - a ` WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is icaled. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: XL- -compensation section need not be completed U the permit is valued at one hundred dollars($100)or less.) Lcertify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' —lewdly law- •mla,end agree the if I should become lett to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with the (Applicant Signature: eaor. � � .—P ?Deter 9/9--a,5 WARMNG:FAILURE TO SECURE WORKERS'COMP S ON COVERA E IS UNIAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,CO3),IN ADDMON TO TH OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATrORNEYs FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect.Lic.a Class e Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure Is not intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet In depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,fatsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Dote: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I W III the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ___ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), • 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this implication appemcons it for suchconstruction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IYes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a school? 0 Yes 0 No (Ii yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _.i_... ...._.___._nother.___ _ _ _ _.. 7 Ifa a permit fromu the South Coast res prescribed Management Californiaal or Sr airpollution control district3 agency is required for the work which is the subject of this application,have all of the disclosures by Callfoia Health and Safety Code Section 42303 been made? 0 Yes 0 No B (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signal a Of Leg ner(s) Date /c4"—oS CODE I INSPECTION TYPE IMIE MEMO LODEt INSPECTION TYPE PATE IMO 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall _ 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy DECLARATION OF AUTHORITY Bldg. Permit# FOR AGENTS OF PROPERTY OWNER TO APPLY FOR PERMITS This Permit# -61 Street Address: 3/a ao 'S� AP Number: f. I (we), . ,1tiES L Co G L / N S , declare that I am the Owner of Title of the above referenced real property,and that I (we)hereby authorize: 4 ` 6/ Name: PO rl4A-' . �GP//�•(/s Telephone Number: 6/ Y4l 6)91-- 0 c 3 p • Street Address: 6-o 9/ /1/41,-VE R CA/ City: CPC/cJ_ftr 77A State: c<} Zip: © 270 to obtain permits in my behalf,as owner/builder,for YATC T/g L De,/0. o F L-LE c R/c I at the above referenced property. Pt ci 23' / vc-- 2. Should any person become an employee engaged in the improvement of the property, I (we)shall immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa,as required by State of California laws. 3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjury that the foregoing is true and correct.eet y Executed this /Q day of Se/01 20 0 f at/ '.ev Piga r S15 4c...9 California. Print Name: - " x Signatur : _A • Date: SUPT. /9 a co r Note: This authorization does not grant authorization to perform the work as owner, it solely provides for limited power of attomey to secure this permit in any behalf. 0779-46(rev.11/00) i CITY OF COSTA MESA BUILDING DIVISION -einee,'"4 F I " DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT M05-00531 (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,COSTA MESA,CA 92626 MECHANICAL PERMIT Job Address: 312 E 20TH ST Status: ISSUED Suite No Applied: 09/19/2005 Issued: 09/19/2005 Vicinity: ILLEGAL UNIT,314 Parcel Number: 42622141 ISSUED BY: Applicant: STEPHENS, ROMAN Address: 5091 HAMER LANE Phone: 949-689-0539 PLACENITA,CA Zip: 92870 Owner COLLINS, JAMES B. AND LORIE R. Address: 2025 W.BALBOABLVD. I .* .Q Phone: 119 NEWPORT BEACH,CA Zip: 92663 r,■'y IS Contractor: OWNER-BUILDER ^y�7'�'' Address: Phone: Zip: License:000000 SCOPE OF PERMIT _ REMOVE MECHANICAL FIXTURES IN ILLEGAL UNIT,314 E 20TH STREET. 12A- G0•5 - I) ]„(h FEE SUMMARY vv �r Quantity Quantity ISSUE FEE $23.50 Repair/Alt Absorbtion Unit $0.00 0 Inst FAU<100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU>100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst/Rep.Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys<100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys>100 k BTU $0.00 0 Compressors/Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 0 15 To 30 hp/1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp/1,750 k BTU $0.00 0 Vent Fan/Single Duct $0.00 0 Over 50 hp/Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 r Inst or Relocate Appl Vent $0.00 0 15 to30 hp $0.00 0 Air Handlers< 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers> 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee. $33.30 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $66.60 COMMENTS I SPECIAL CONDITIONS • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord. No.92-28,§1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days,or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable! codes, all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)754-5626 2448-48(6/00) DECLARATIONS r WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed It the permit is valued at one hundred dollars($100)or less.) prnc�ertdy that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the workers' comply witthes law mia,and agree that If I shculdM t to the workers'compensation provisions of Section 3700 of the Labor Code,I shell forthwith comply withan provisi S. G A,p)izant:Slgnatare: trema ••••• of Datc—a-�."-x 9—/T-a 5- WARNING: WARNING:FAILURE TO SECURE WORKERS' PE ATION COVE GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($700,000),IN ADOMON TO COST OF COMPENSATION.DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force end effect.Lic.N ,__ Class e Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): , ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 704.4,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of property who builds or Improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: - Date: Owner ID verified by drivers license. 0 Yes 0 No Drivers License No. Expires: Verification of Ownership by(type of document,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person Is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsawork,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2.Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder,I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 No (Section 25505 of the California Health and Safety Code requires,with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, r or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of r compressed gas at standard temperature and pressure). __ _t...__.._ ____...._...._.....____— _ _..._ _ r_ _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous rrleterials)7 ❑yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the Califomia Health antl Salery Code been fully complied with? 0 Yes ❑No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this implication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control dlstdct or agency? IYes LJ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ..._ Management _ _ _..__ubject .. 7 a a permitn fromn the SouthteCoast s Quality ed by District or other airpollution coon 4l district3 or agency is required for the work which is the subject of this application,have all of the disclosures prescnbed by CaliforniaCalfoHealth and Safety Code Section 42303 been made? ❑Yes ❑No 8 (If yes",attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for Inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI• elute Of L al Ow (s) Date Of utho Applicant Dalt„„„.„."-^-7,-,, -,. CODE I INSPECTION TYPE PATE MALI CODE! INSPECTION TYPE all HOW 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy j1J! CITY OF COSTA MESA BUILDING DIVISION ). f ai &. DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER i.4t I . PERMIT P05-00721 (714)754-5273 • Fax(714)754-4856 • www.cl.costa-mesa 1ghi MBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 312.E 20TH ST . Status: ISSUED Suite No Applied: 09/19/2005 Issued: 09/19/2005 Vicinity: ILLEGAL UNIT,314 Parcel Nunmber: 42622141 Applicant: STEPHENS, ROMAN /� ISSUED BY: Address: 5091 HAMER LANE Phone: 949-689-0539 PLACENITA,CA Zip: 92870 OwnAddress COLLINS,25W.BAJAMES B. AND LORIE R. Address 2025 W.BALBOABLVD. I Phone: iI� NEWPORT BEACH,CA Zip: 92663 Y js Y' �3� Contractor OWNER-BUILDER oA' 5 Address: Phone: Zip: License: 000000 a SCOPE OF PERMIT 1 SEWER CAP FOR REMOVAL OF ILLEGAL UNIT,314 E 20TH STREET. (1 .R c- libel FEE SUMMARY �C� ' AMT QTY AMT OTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher • $0.00 0 Sewer Cap for Demo $9.80 1 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0 • Drain,Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 ' Gas(1-4 outlets) $0.00 0 Sink,kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa(private) $0.00 0 VIOLATION $33.30 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 • REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 , TOTAL CALCULATED FEES: $66.60 COMMENTS/SPECIAL CONDITIONS • NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.(Ord.No.92-28,§ 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned fora period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained.Failure to obtain Inspections and final approval will result in the expiratio�:Ihis permit. FOR INSPECTIONS CALL: (714)754-5626 244646(6/00) DECLARATIONS WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Cartier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars($100)or less.) C -(4r-Icer-- ---y that In the performance of the work for which this permit is Issued,I shall not employ any person in any manner so as to become subject to the workers' compensation laws yY6e0(omia,and Aare- that if I should b;/mo subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shell forthwith comply with dies rovivis/iods. G G Applicem'Slgllature" I�Y*'G^ I/ /' Date;r9-/f or WARNING:FAILURE TO SECURE WORKERS'•u ENSATION a ERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($103.000),IN ADDmON 7 r HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect.Uc.a Class fl Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not Intended or offered for sale(Sec. 7044,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such Improvements are not intended or offered for sale.If,however,the building or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I,as owner of the properly,em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not appy to an owner of properly who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑Yes 0 No Driver's Ucense No. Expires: Verification of Ownership by(type of document,I.e.-properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth Into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding,falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,Califomla Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑Yes 0 No (Section 25505 of the Califomia Health and Safety Code requires.with some exceptions,that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, L or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to filo a registration0-Ne form for acutely hazardous materials? ❑Yes No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑yes 0 N (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 of the Califomla Health and Safety Code been fully complied with? 0 Yes - 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If yes",the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _______ Management _ __ _. _._.._o__s.._ __o_..._ —_—. _. 7 Ifa a cation tram the South Coast res Quality ed by Califomla a Healtheal or other egold tioncton 4l 3i 3 beenlct agency is required far the work which is the subject of this application,have all of the disclosures prescribed by Califomla and Safety Code Section 42303 made? 0 Yes 0 No 8 (If yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPUANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signal re Of L:nal OwnerJ' - er 9 /F-es"' Date t i thollz.._Appfcanl= - D te— LooE I INSPECTION TYPE PATE IfUMLA CODE It INSPECTION TYPE PATE DITIDALE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical '201 Final Block/Retaining Wall 212 Final Fire Prevention '202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition • 250 Final Building/Occupancy 1 P, 4`,5" F CITY OF COSTA MESA i, ^ ' � .. BUILDING DIVISION > y�,,' DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER J. se y�,��,�,�lrinii ill PERMIT 3� 06-00161 -"olonaruo Se (714)754-5273 • Fax(714)754-4856 • www.ci.costa-mesac PLUMBING PERMIT 77 FAIR DRIVE,COSTA MESA,CA 92626 Job Address: 312 E 20TH ST Status: ISSUED Suite No Applied: 03/10/2006 Issued: 03/10/2006 Vicinity: Parcel Nunmber: 42622141 Applicant: ROMAN STEVENS ISSUED BY: Address: Phone: 949-689-0539 Zip: 92663 Owner: COLLINS, JAMES B. AND LORIE R. Address 2025 W. BAL6OABLVD. Phone: NEWPORT BEACH,CA Zip: 92663 Contractor: OWNER-BUILDER Address: Phone: Zip: License: 000000 SCOPE OF PERMIT REPLACE UNDERGROUND GAS LINE. FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub/Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P-Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping(per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect(Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain,Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain,Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet(Toilet) $0.00 0 Drain,Roof $0.00 0 Shower $0.00 0 Water Heater/vent $0.00 0 Drinking Fountain $0.00 0 Sink,bar $0.00 0 Water Piping(Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink,commercial $0.00 0 Water Re-pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink,Floor $0.00 0 Water Service $0.00 0 Gas(1-4 outlets) $0.00 0 Sink,kitchen $0.00 0 Water Softener $0.00 0 Gas(Over 4 outlets) $0.00 0 Sink,service/mop $0.00 0 OTHER $0.00 Gas Repipe $9.80 1 Spa(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa(public) $0.00 0 PLAN CHECK $0.00 Interceptors(Grease,Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors(Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $33.30 COMMENTS/ SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord.No.92-28,§ 1, 12-21-92) • EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,or if work is suspended or abandoned for a period of,180 days. • INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained.Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714)7545626 2446-46(6/00) DECLARATIONS. -- WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: '. . -, ❑ I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑ I have and will maintain workers'compensation insurance,as required by section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My workers'compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit Is valued at one hundred dollars($100)or less.) ❑ I certify that in the performance of the work for which this permit is issued.I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect.Lic.# Class# Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason(Sec.7031.5,Business and Professions Code:Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as their sole compensation,WILL DO THE WORK,and the structure is not intended or offered for sale(Sec. 7044.Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I,as owner of the property,am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project(Sec.7044,Business and Professions Code:The contractors License Law does not apply to an owner of properly who builds or improves thereon,and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). � may. der sec. • / Business and Professions Code for this reason: •- IOr uaa•-....�rjr . Date: 11: i —i �C Owner ID verified by driver's lice 'e. Ix-l�'/es 0 No T 'ver's Lice . No. ! xpir.s: Verification of Ownership by(type of documeSt,i.e.-property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by this permit,and that no building structure,scaffolding.falsework,or demolition or dismantling thereof,will be more than thirty-six(36)feet high.(Chap.3.2,Grp 2,Art 2,Sec. 341,Title 8,California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety,as noted above,unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes 0 NO (Section 25505 of the California Health and Safety Code requires,with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds,or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the California Health and Safety Code,with some exceptions,requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP(Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation,certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required,has Section 25534 01 the California Health and Safety Code been fully complied with? 0 Yes 0 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any pert of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 Yes 0 No (If'yes',the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application,have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes 0 No 8 (If"yes',attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction,and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes.I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I atu - Of Lege �— / Data s�itCc>:�_ �A • •rAut prized Applica Dal COPE♦ INSPECTION TYPE RAIL INTRIAL@ CODE Y INSPECTION TYPE PAIL INTITIAIQ 1616 Fixed System Final Fire Prevention 206 Final Mechanical Q 1266 Pool Spa Final 208 Final Plumbing A A 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 1 • DECLARATION OF AUTHORITY Bldg. Permit# FOR AGENTS OF PROPERTY OWNER This Permit# TO APPLY FOR PERMITS Street Address: 3� 2 �� - QST AP Number: 1. I (we), 3- 4MEs Co , L / N S , declare that I am the Owner of Title of the above referenced real property, and that I (we)hereby authorize:au� y (� Name: rl O /�'1f�/V ZS: u�e( /V SST's Telephone Number: e/ Y4) 6 69- 0 c 3 7 Street Address: 6...0 9, f/i�gea CA/ City: �i Cnor. rr7-4 State: c4 Zip: 9. 27o to obtain permits in my behalf,as owner/builder,for PA r//3 G DiS yo. D F CCE C i R/C y at the above referenced property. Pt uiy S /a/- 2. Should any person become an employee engaged in the improvement of the property, I (we)shall immediately provide Worker's Compensation Insurance coverage and cause a certificate of that coverage to be filed with the Building Division of the City of Costa Mesa, as required by State of California laws. 3. As owner/builder in fact, I understand and accept that my responsibilities do not transfer to any other person, company or corporation. 4. I agree to indemnify and hold the City of Costa Mesa and its employees or officers harmless from any claim resulting in damage or personal injury to myself or any other parties as a result of work authorized by the permits from the City of Costa Mesa. 5. I declare under the penalty of perjurythatthe foregoing is true and correct. �/ Executed this 'nettday of JIEP/. 20 0 C at.12Cm,f�Qr 434C 4 C-/4 California. Print Name: --------MAPY /--�. Aired S xSignatur : Date: .SLEPT , 9 a co Note: This authorization does not grant authorization to perform the work as owner, it solely provides for limited power of attorney to secure this permit in any behalf. 0779-46(rev.11(00)